Mile 14020 + 1804.2: Catching-Up

Above: A shot from one of the overpasses at UHS Wilson Medical Center in Johnson City, NY.

The whole last four weeks were both absolutely busy and awesome. So, here's a retrospective entry on a lot I haven't talked about, and we'll get caught up this week (hopefully). Due to the above, I left the odometer at the mileage before hitting the road today.

THE ROADS WEREN'T EXACTLY
FRIENDLY.

My last night in Decatur wasn't exactly just spent packing. I actually went to a journal club that night with a couple of the residents. A few of the discussions that they had really got me thinking. Now, I think that the current debate on how effective kyphoplasty and vertebroplasty actually are on curing pain for spinal fractures is a good one to look at (and right now the best study shows that it isn't). However, the whole time I was thinking... evidence-based medicine (EBM) against basic-science-based medicine. A lot can be explained with pathophysiology, but theoretical doesn't mean its proven. And that's where evidence-based medicine comes in, the proof that theory works (or doesn't). However, a lot of the ideas where studies for EBM come from either come from basic-sciences or practicality. So, in short, they both go hand in hand.

And 36 hours later after I finished in Decatur, I found myself amongst the Appalachian hills of Upstate New York. The trip wasn't exactly the friendliest, as snow dominated my trip on I-86 in Western New York. Some of the roads I passed only had one lane plowed, and I had to make the ultimate winter road trip decision... Take the plowed lane with potholes the size of montana, or the unplowed lane without them. But I ended up in Johnson City, NY safely. My four weeks on the wards of Internal Medicine for my Subinternship were quite intense, but very enjoyable. One of the things I liked about both of my Internal Med rotations (Core & Sub-I) was teamwork that's necessary to keep things running on the floors and in the hospitals. Somehow different combinations of residents, students, and attendings seem to always work out. But as I may have written before, every time I get into a rhythm of things, I have to move on for my next rotation. I can't wait for residency, as I finally can get into a rhythm with my colleagues for a good three years.

Well, I'm tired after a long day of driving... So, more thoughts on my last four weeks on Internal Medicine and on what's going on with my stop in Columbus tomorrow.

Mile 8895: Keep on Moving

Above: I do miss the 6 AM rush hour.

ALTHOUGH I MISS INTERNAL MEDICINE,
THE ADVENTURE MUST CONTINUE.

And just like that... it's over. One of the odd ways I've thought about the last 16 weeks is, I've been at the hospital 4 weeks longer than the current interns.

My last 16 weeks at Westlake Hospital were absolutely amazing.

Some of the biggest lessons that I learned during my time in Infectious Disease weren't even in infection (although, with the amount of cellulitis cases that we got called for, I would almost consider myself an expert in cellulitis now). When comparing my 12 weeks on the floors, where we took care of just about every single aspect of our patients, my 4 weeks on infectious disease were simply focused on that. I still remember the first day when I was on "floor mode" - as I liked to term it - and wrote just about every single assessment and plan on the patient I could in my note. I quickly learned that was quite inefficient considering I was on a consulting service. But this is one reason that I couldn't see myself - at this moment - going into a subspecialty; I feel odd treating only one aspect of a patient.

One thing that I really enjoyed was that my Infectious Disease rotation came right after my Internal Medicine rotation and at exactly the same hospital. I knew how the teams worked along with who worked the teams, which not only made the transition easy, but I appreciated how the tables turned. On the floors, my intern would let me know what consults I need to pull, but now the interns were coming to my doctor and me with new consults. I'm going to miss the rhythm I started putting together with the interns, seniors, and students, but I must keep moving...

It was with this program that I appreciated some of the aspects of smaller community programs, getting to know everyone's face, seeing common cases repetitively (i.e. like the cellulitis above), working with tight knit teams, and sometimes seeing patients over and over again. I've been a big fan of the "make a big world a small one" concept, and community-type residency programs attract me in that manner.

For the next 3 weeks, I have them off, but starting in late September begins my Psychiatry rotation at Jackson Park Hospital. But I tell you, I surely am going to miss running up and down those floors.

A huge thank you goes out to the attendings, residents, and students at Westlake.

Mile 8052: Teaching an old dog new tricks

Above: Jon, John, and Khoi and myself enjoying a night out at an Ethiopian restaurant after our final day.

ON MY LAST DAY
I BROKE A SWEAT.

7:40 PM Friday. I never really had Ethiopian food before. I'm very glad that one of our colleagues Jonathan had brought up the idea. You basically go in, and all the stuff that's ordered comes out on this huge platter. If you've been to Maggiano's or some other "family style" Italian eatery, you know how family style works. But I learned that Ethiopian family style is much more adventurous... it involves eating with your hands. I never imagined that eating with my hands could be so enjoyable... and so tasty!

Who knew that at the end of a medical rotation, I'd still have the brain capacity to learn something new.

-----

It's the end of my twelve weeks here for Internal Medicine. Before I keep going, I apologize for not writing more during those twelve: it was that intensive. I admit that its tough for me to study at home even more now, because I guess I've conditioned myself to take home as a place of rest. Even with coffee, I sometimes struggle with trying to make it through the latest literature or even just high yield Step 2 studying.

Am I glad its over? In ways yes, and in other ways, no. Yes, I'm tired. Yes, I need a vacation (even though I had an awesome one a few months ago). But I loved my group (we all had a rhythm and enjoyed each other's contributions to the team), and also what I had learned in the last few weeks. One of the attendings had said to us that learning medicine was the essence of repetition, and I'll admit that seeing dozens of many cases made me get into a rhythm of what to look for while taking a history and the direction to take when managing a patient. I loved running the floors, writing notes, and working with nurses, attendings, and case managers. I really had the feeling of what residency would be like in internal medicine.

What's next for me? Well, same place, but second verse. It's time for a little adventure into the world of Infectious Disease (ID) for four weeks. Think of it as an extension of Internal Medicine. So during the next few weeks, I'll try to replay some of my experiences during IM, and also try to expand on what exactly ID brings for me.

Mile 7166: Teaching the Ropes

Above: A well deserved 7000 mile car wash.

I LOVE IT WHEN
THE TABLES ARE TURNED.

At points in the last four weeks, I've felt like I've become the intern at times.

Traditionally, every four weeks during our twelve-week rotation, we switch interns and teams to give us an idea of how rotating in a residency program feels. However, for the first switch after my first four weeks, we didn't switch teams. If we had, it might have been a mortal mistake.

Why? The caveat was that the timing of the switch matched to the time my hospital injected new interns into the 4-week rotation last month. When I say new, I mean "Just-Out-of-Match-2010" new.

Many of the interns at the hospital I am at had just simply survived a week of orientation at the hospital, and were all of a sudden thrown into the "real world." I have heard many of my friends who have gone through residency talk about the adjustment into residency and how hard it is, but here I was, along with six other medical students to see it first hand. I haven't seen as many blood shot and baggy eyes at any other point in my life than these four weeks! Some of them started to even question what they got themselves into (that was part of what I termed the post on-call syndrome.)

In some ways we knew more than the new interns.

Working four weeks at the hospital was actually four weeks more than some of the interns. Over the first four weeks, our rhythm on the wards was finally taking shape, we knew how the different rounds were scheduled, we knew where to grab the empty forms when needed, and we even knew the secret places in the hospital to get coffee. However, the most important thing that I saw during the intern switch up was how well we knew the patients on our teams; had we done the traditional team switch, that continuity of information may have been lost.

But over the last few weeks, it was odd to be teaching interns the "ropes" of the hospital. I mean, the interns knew a lot more about medicine (they finished school!), but I guess the working mindset is what we needed to teach them. The hospital world is now theirs, but now it it is time for them to make it their own. Each one of us medical students made sure that we gave the interns a framework to build on to make sure that their time at the hospital was successful. It was an odd way of learning for us students, as the last few weeks was a great lesson in learning how to teach.

Well, four weeks have passed. My intern has not only survived, but has changed since the first few days at the program; he's more comfortable with the ropes and is starting to get his rhythm with working the floors. But it's time for a new intern, and because not all the new interns for the residency IM program here have been on the floors, it's time to teach again for a second time around. It felt awesome to have been a part of my interns first four weeks in residency, and it felt awesome to be an intrinsic part of a medical team.

And here begins my last four weeks of internal medicine. I'll admit, its getting rather bittersweet.

Mile 6650: Aha! That could be it!

Above: The weirdest sign I saw on my May 2010 roadtrip. Talk about a one-stop tourist trap. Kissimmee, FL along Route 192.

It's been busy. There's no time to sit back and relax. Things aren't stopping. And for me, stopping could be dangerous.

BUT I LOVE THE BURN.

Week 6 here at my internal medicine rotation. I finally got the layout of my hospital down, know when and where to get coffee on my commute, what entrees at the cafeteria I should have/avoid, and even where the "secret rooms" are to do my work.

The importance of the IM rotation for anyone comes not in just getting to work in a hospitalist format, but also learning the art of medical thinking... something that I am still in awe of and want to master.

ONE CAN NEVER SAY A DIAGNOSIS IS CLEAR CUT.

It never is (unlike many medical dramas on TV put it). Its a common fallacy I run into. To me, Step 1 thinking is all about the "clear-cut" ness and classical cases, but coming into Step 2 and Step 3, things are completely different. If Step 1 thinking is taken into clinical medicine, fairly significant diagnoses can be missed, and one can head down the wrong road of management. Medicine kinda breaks the rules; it is unsafe to always think that X + Y + Z = A always. After a set of what we call "differential diagnoses" are given out (these are the lists of possible things that are going on), it is up to the clinician to rule out specific ones (especially ones with the most deadly prognoses along with the most common). A good set of differentials actually leads to better diagnostics and therefore, management.

Our tools to solving the patient's issues include the history we take on the patient, the physical exam, and laboratory tests. Each one of the tools has an advantage / disadvantage, usually measured in terms of cost (dollars and cents), usefulness of the info returned by the test, and time-to-benefit ratio (waiting 3 days for confirming something that might kill you in an hour isn't exactly a good thing). Some of the best clinicians I've seen at the hospital will perfectly balance all three by picking the right questions, exam procedures, and tests to confirm and rule out diagnoses (somehow they make the puzzle pieces fit). I'll admit, to use all these options efficiently is an art, and my mentors (attendings, seniors, and even the new interns) are always able to think of something I can't.

It's amazing that a lot of them say that the history is usually the best place to find out the diagnosis. However, even for the best clinicians, there are times where cases where the diagnosis is so unclear or takes an unexpected turn that a "Hail Mary" throw of tests needs to be done. But they're so good that this is usually last resort only.

The art of being a clinician is easy to put into words, but mastering it in practice is going to take more than 6 weeks to accomplish.

Mile 5998: Fritos & Coffee

Above: Roadside stands like these are available all thoughout Georgia. I get my load of honey-roasted pecans each time I pass here.

EVEN WHEN ITS ONLY FIFTY-DEGREES OUTSIDE,
MY WINDOWS ARE DOWN.

Every minute seems to blur into another, as the weeks pass by faster and faster. We're already in our third week (about to start our fourth), and it was only yesterday that I remember we were getting into the realm of things. The one thing I like about the internal medicine (IM) rotation I currently am at is that it satisfies the standards that I had set at Mile Zero on my journey very well. Doing this rotation actually makes me rather excited about IM. Our work on the floors has the quality of intensity, something I have been desiring for some time.

The following is a normal itinerary for me on a weekday.

6:00 AM - I leave home early. In Chicago, traffic accumulates with every minute lost in the morning, so this is the absolute goal for departure. Although I don't have to be at the hospital until 7:30, I'd rather do some reading in the resident's lounge than waste more time stuck in traffic. I usually get to the hospital about 6:30 AM, and when I get there, I'm loading up patient data from the computers and visiting the patients I'm following before my intern arrives.

7:30 AM - My intern arrives. The first thing he does is make coffee at the maker in the resident's lounge. On the table in front of the maker is an aluminum tray with a few juice cups and bags of snacks that the hospital delivers for the on-call team for the night. He usually isn't able to grab breakfast in the morning, so he grabs a bag of chips and opens it up for breakfast. Not leaving my resident alone with the morning ritual (even though I already had my Frosted Wheat Puffs and Ovaltine earlier this morning), I usually pull up a bag of Fritos (or Cheetos, as a viable alternate) and get a cup of coffee.

This is a superb example of a resident-recommended diet.

8:00 AM - I round with my intern, releasing the data from the labs I pull in the morning and the data I pulled on the history of the patients I'm following. These rounds are walking-intensive (involving going up and down several floors and down several wings) and can slow down whenever patient demands in the ICU or on the floor come up. I usually find myself walking around in "shadow mode" sometimes, leading myself to walk exactly in the footsteps of my intern (which could have me backing up into walls or other health care staff).

10:00 AM or thereabout - On some days, we have what they call "teaching rounds," with a senior attending physician along with our group of interns and students (about 8 in total), which involves a component of lectures, bedside patient presentations, and resident/student presentations. This is one of the lecture components provided. I believe that lectures are good to recap what's going on in the hospital. Getting lost in the demands that the rotation/residency provides is easy; we can't forget we have to learn every step of the way.

12:00 PM - We have another didactic lecture over lunch, on a hot health topic. This usually takes place in the lecture hall and makes our day more efficient, by giving us a good time to combine eating while our learning. Time management and efficiency is critical to operating and being successful in residency.

1:00 PM - I sit down and write progress notes on patients I'm following. The afternoon is usually left to admitting new patients, taking their histories/doing physical examinations, running actions/plans past my intern, and reading up on their cases. Medical education is very reliant on real cases, and that's a good thing. It's not the same reading about a topic in a book. Each medical case encompasses critical thinking skills and problem solving. Memorization won't get a physician anywhere.

5:00 PM - By this time I'm ready to leave the hospital if I did everything right. Sometimes there are exceptions, either late (or multiple) admissions, falling behind on notes, and the occasional assisting the intern, so he can get stuff done earlier. But in the end, I don't see the way I work with my intern as senior-junior, but in many ways it ends up as a team. I think that's just really cool, because that team combo has enhanced my learning experiences in medicine.

6:00 PM - After some time in traffic, I stop by one of the nearby Caribou Coffees or Starbucks and pick up a good iced coffee that powers me for the rest of the day. That night, I read up on primary literature for my cases and lectures, and I finally get to bed by about 11:00 PM.

And with that (and some occasional changes day-by-day), it's simply rinse and repeat for the next day at work. Weekends are a tad shorter (ending by 3:30 PM), but the same routine above follows. I'll be shooting out more specifics on what goes on during my internal medicine rotation, so stay tuned.

Mile 5855: Shortie: Whoa!

Above: Jurassic Park truly exists, Folks. Along I-65 in Kentucky.

THIS EXPERIENCE MAKES ME GO
WHOA!

I was talking to my friend Nik about not writing for 3 weeks, and I said to myself, "Wow, I went about 500 miles without letting you know where I went. That's kinda like going to Nashville and leaving you behind in Chicago."

Sorry. Let's get you caught up.

The last three weeks have been some of the busiest med schooling I've gotten so far. At a teaching hospital in Chicago, I'm currently doing Internal Medicine. The program set up is a shadowing of an intern both on the wards and in the ICU (depending on what patients are assigned to him). And I've done a lot of walking, writing, and paging (the last one's my favorite... I get to proclaim myself as a "medical student" on the phone!). I've seen some awesome cases at the hospital left and right, presented in front of interns and staff, and felt an intensity that I've been wanting to have in medicine for a while. Sometimes I get home with a load of primary literature I need to dig through!

But I'll tell you this, an intense rotation can be quite exhilarating, but it can also be more tiring too. All in all, the work here makes me love medicine so much more. My homework: get you some concrete examples of my experience this weekend. I won't leave you behind on the trip for much longer.